Identify patients with contraindications to exercise testing.

The following absolute contraindications to exercise testing are adapted from the ACC/AHA Guidelines for Exercise Testing (1997):

•  Acute myocardial infarction (AMI), within 2 days
  
•  Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise
  
•  Symptomatic severe aortic stenosis
  
•  Uncontrolled symptomatic heart failure
  
•  Acute pulmonary embolus or pulmonary infarction
  
•  Acute myocarditis or pericarditis
  
•  Acute aortic dissection

In the past unstable angina was a contraindication to exercise testing. However, exercise treadmill and pharmacologic testing are safe in low-risk outpatients with unstable angina and in intermediate-risk patients in whom an MI has been ruled out and who are free of angina and congestive heart failure. (ACC/AHA Stable Angina, 1999)

The following relative contraindications to exercise testing are adapted from the ACC/AHA Guidelines for Exercise Testing (1997):

•  Left main coronary stenosis
  
•  Moderate stenotic valvular heart disease
  
•  Electrolyte abnormalities
  
•  Systolic hypertension >200 mm Hg
  
•  Diastolic blood pressure >110 mm Hg
  
•  Tachyarrhythmias or bradyarrhythmias
  
•  Hypertrophic cardiomyopathy and other forms of outflow tract obstruction
  
•  Mental or physical impairment leading to the inability to adequately exercise
  
•  High-degree atrioventricular block

Relative contraindications to exercise testing can be overridden if the benefits of exercise outweigh the risks. These contraindications should be correlated with the results of a clinical evaluation, in consultation with a cardiologist, as needed.

Contraindications to EST also include disabling arthritis, amputation, severe peripheral vascular disease, severe chronic obstructive pulmonary disease (COPD), and general disability. The presence of one or more contraindications will either make EST impossible for the patient or result in unreliable/unusable test findings (AHCPR USA, 1994). Alternatives to standard stress testing include a six-minute walk test and upper body ergometry testing. Pharmacological stress testing does not provide data for exercise prescription development.

Contraindications to stress testing are not limited to the condition of the patient. There are also confounders of electrocardiogram (ECG) data that make EST inappropriate without an imaging modality (e.g., the presence of a left bundle branch block (LBBB), left ventricular (LV) hypertrophy with repolarization abnormalities, resting ST-segment depression >1mm, and digoxin therapy). Refer to Module F, Annotation F. *Note: This link will take you out of Module E.